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Conquering the doctor shortage

CINCINNATI -- Waiting weeks to see a doctor. Scrambling to find one. Foregoing care altogether. Is this our future? America already doesn't have enough doctors, with a shortage of 45,000 forecast by 2020.

CINCINNATI -- Waiting weeks to see a doctor. Scrambling to find one. Foregoing care altogether. Is this our future?

America already doesn't have enough doctors, with a shortage of 45,000 forecast by 2020. Exacerbating the shortage: Millions of people have new access to health coverage under the Affordable Care Act, also known as "Obamacare." Meanwhile, U.S. health care is focusing more on prevention, not fixing problems, which takes time and resources.

Expanded roles for nurse practitioners and physician assistants – also in short supply – could ease the manpower void, experts say. But that would require changing regulations as well as the mindsets of some physicians and consumers.

A Cincinnati Enquirer analysis of U.S. Labor Department workforce data shows there are far fewer nurse practitioners and physician assistants than doctors locally, calling into question just how soon the gap of health care providers can be plugged.

"This is a very serious problem that we need to jump on now, so that we're not caught in a very bad situation later," said Diann Nelson-Houser, president-elect of Ohio Association of Advanced Practice Nurses.

Across the Cincinnati region, physicians outnumbered nurse practitioners by a 3-1 ratio in 2012, according to the most recent workforce data. For every 10 doctors there was only one physician assistant. Statewide, there is just one nurse practitioner for every four physicians, and one physician's assistant for every seven doctors, according to the data.

The pipeline of students in these fields has been growing, but officials say it will also take major changes in the way health care is delivered, paid for and received to address the shortage. "There is a profound mismatch between providers and the need of medical care," said Dr. Myles Pensak, CEO of UC Health Physicians.

Increased reliance on nurse practitioners and physician assistants was one way that Massachusetts cut wait times once more people got insurance coverage through Romneycare.

"We call them physician extenders, because they provide support to physicians, and in the case of nurse practitioners, many may have their own caseload," said Jennifer Jackson, UC Health's vice president and chief nursing officer.

Nurse practitioners and physician assistants receive less medical education than physicians. Both require master's degrees in their field, which can take two to four years following a four-year undergrad program.

They make less than doctors, too, which some argue helps offset costs to patients. Nationwide, nurse practitioners make about $93,000 a year, while physician assistants earn about $102,000, according to 2012 federal data. That compares with an average annual salary of about $160,000 for a physician.

Depending on the state where they practice, nurse practitioners and physician assistants perform many of the same duties as a doctor, including diagnosis and treating certain illness and prescribing some medications.

But some health care leaders say restrictive regulations – including those on the books in Ohio, Kentucky and Indiana – limit nurse practitioners from reaching more patients.

"Nurse practitioners (in Ohio) are required to practice in collaboration with a physician," said Nelson-Houser, who operates a nurse-managed health care center in the Columbus suburb of Gahanna, where patients only see nurse practitioners.

Ohio law, which is similar to those in more than a dozen other states, requires Nelson-Houser to have a "standard care arrangement" in place with a physician, which ensures that a doctor is available around-the-clock – even if just by telephone or email to seek medical advice should she need it. The agreement also outlines parameters under which her clinic can prescribe drugs, and requires that her operations be evaluated twice a year. The agreement, which Nelson-Houser pays a provider to enter into, must be renegotiated each year.

Yet as more primary care doctors are acquired by health systems, Nelson-Houser says it's getting harder for clinics like hers, which sees about 1,500 patients a year, to find partnering physicians. "If you're not part of that health system, it's tough to find a collaborator," she said.

Nationally, some groups representing doctors are resisting efforts to allow nurse practitioners to practice completely independently from physicians. They say patient safety is at risk if there is no physician oversight.

"There have been numerous studies that compare nurse practitioners to physicians that have delivered results that show similar outcomes," countered Nelson-Houser.

The other problem standing in the way of change are attitudes of some consumers and doctors.

Consumers accustomed to always seeing a doctor may have to rethink their views. "The classic health care model that many of us grew up in is no longer sustainable," said UC Health Physicians' Pensak.

"We first have some education to do with physicians about the role of nurse practitioners and physicians assistants," said Joni McElroy, chief operating officer of Mercy Health Physicians. "I have some physicians raising their hand to work with a nurse practitioner. I have some who say, 'No way,' and many more who are on the fence or just curious."

Yet Mercy Health already employs 69 nurse practitioners and physician assistants, more than double the number it had 2012, said McElroy.

Mercy Health also has four open nurse practitioner positions, and McElroy said there is no shortage of applications, the result of ramped up programming at area colleges in recent years.

In Northern Kentucky, St. Elizabeth Healthcare has been growing its network of walk-in clinics staffed by nurse practitioners. This month, it opened an Express Care in Independence, where nurse practitioners can can treat and assess patients for minor medical issues, similar to the services provided by walk-in clinics at retail pharmacies.

Pensak says he sees "unlimited growth and opportunity" for nurse practitioners and physician assistants. His system employs more than 250 now.

Last year, UC aligned itself with The Little Clinic, which staffs its walk-in clinics at Kroger stores locally with nurse practitioners. "This really affords us front line interface with patients, and allow for prompt access for patients when they need to be seen," he said.